MED PASS® Medication Pass Program

Unintended Weight Loss—Identification and Prevention

Objectives:

Participant will be able to:

  • understand the relationship of weight loss and common conditions affecting the long term care resident
  • identify the risk factors associated with unintended weight loss
  • evaluate effective nutrition intervention programs
  • implement a Medication Pass* Supplementation Program
  • evaluate the effectiveness of a weight management program

* MED PASS® 2.0/MED PASS® No Sugar Added (NSA)

I. Effects of Weight Loss & Undernutrition

Anorexia and weight loss are the most prevalent nutritional disorders found in the long term care (LTC) setting. Common conditions associated with undernutrition include:

  • pressure ulcers
  • anemia
  • immune dysfunction
  • muscle weakness
  • infections
  • fatigue
  • hip fracture
  • edema
  • cognitive abnormalities
  • mortality

The prevalence of undernutrition in LTC facilities has been reported to range from 20% - 54%. Undernutrition can be related to unintentional weight loss, vitamin/mineral deficiencies and protein-energy malnutrition. One study, based on the MDS, found that 9.9% of residents had lost 5% of their weight in 30 days or 10% of their weight in 180 days.

II. Identification of Risk Factors

An initial nutritional assessment is key in identifying clinical conditions that may put the residents at risk for unintended weight loss. Based on the May 1999 HCFA State Operations Manual (SOM), the unintended weight loss investigation survey protocol, the following conditions should be reviewed and documented as potential factors for weight loss:

  • cancer
  • infection
  • renal disease
  • diabetes
  • depression
  • dehydration
  • chronic obstructive pulmonary disease
  • body mass index (BMI) below 19
  • dysphagia
  • endentulousness
  • ill fitting dentures
  • mouth pain
  • taste/sensory changes
  • bedfast

Other factors to identify include total dependence on feeding, pressure ulcers, polypharmacy, abnormal laboratory values associated with malnutrition (Hct/Hgb, BUN/creatinine ratio, potassium, cholesterol, and serum albumin).

Based on the identified risk factors, the resident's nutrition and fluid requirements must be properly assessed, along with their individual dining assistance needs, food cultural/religious preferences, food allergies and frequency of meal requirements.

III. Effective Nutrition Intervention Program

Once the nutritional status of the resident is assessed, a care plan must be developed utilizing the clinical conditions and identified risk factors. Appropriate nutrition interventions, such as oral supplementation, must be planned based on the resident's individual needs. Previously, oral supplements were given between meals or with meals. However, these methods have not always been successful due to:

  • supplements being used as meal replacement vs. additional calories;
  • lack of documentation to verify resident's acceptance;
  • supplements left at nurse's station; and
  • limited achievement of weight gain goals.

The implementation of a medication pass supplement program using MED PASS® 2.0/MED PASS® NSA has proven successful in facilities because the procedure:

  • ensures distribution and consumption of product;
  • allows for more frequent distribution of smaller amounts;
  • does not interfere with meal consumption; and
  • produces positive results (weight gain).

IV. Implementation of MED PASS®* Program (Includes MED PASS® 2.0/MED PASS® NSA)

Implementation of the MED PASS®* Program can be easy to initiate within a facility by using the following Policy and Procedure:

POLICY:

A. Residents identified as nutritionally at risk and who exhibit one or more of the following criteria shall be referred to the MED PASS®* Program. Criteria includes:

  • Poor acceptance of routine between meal supplements.
  • Evidence of significant weight loss (5%) over a 30-day period or exhibited a trend of progressive weight loss over 3-6 months (7.5% - 10%).
  • Inability to tolerate or refusal to accept "normal" volumes of fluids per serving.
  • Diagnosis or conditions requiring increased calories and protein, i.e. Stage II or greater pressure ulcers, cancer therapy, infection, COPD.
  • Low body weight (80% or less of ideal body weight or BMI below 19) and intake less than 50% of meals.

B. Residents identified as nutritionally at risk and exhibit the following criteria shall be referred to the MED PASS® No Sugar Added (NSA) Program.

  • Diagnosis or conditions requiring increased protein and calories with need for controlled carbohydrate intake, i.e. insulin dependent diabetics with Stage II or greater pressure ulcers or multi pressure ulcer sites.

PROCEDURE:

1. Residents will receive 60-90 cc (2-3 oz) of MED PASS® 2.0/MED PASS® NSA at each medication pass based on the resident's individualized med pass routine, care plan and physician order.

2. MED PASS® 2.0 provides 120 calories, 5 gm PRO per 2oz. MED PASS® NSA provides 96 calories, 5 gm PRO and 5.7 gm CHO per 2 oz serving. (3 - 2 oz. servings daily would equal one CHO exchange).

3. The MED PASS® 2.0/MED PASS® NSA order will be placed on the medication administration record (MAR) and signed out as a routine medication or treatment. The amount of MED PASS® 2.0/MED PASS® NSA taken will be documented on the MAR and signed out by the designated person passing the medications.

4. A full day's supply of MED PASS® 2.0/MED PASS® NSA will be delivered from dietary to the nourishment refrigerator located at the nursing Unit on the evening prior to the follow day's supplement pass. If MED PASS® 2.0 remains in nourishment refrigerator at the next delivery, the stock will be rotated by designated delivery person to insure the FIFO (first in, first out) principle.

5. If partial containers of MED PASS® 2.0/MED PASS® NSA are left after a medication pass, the remaining quantity will be stored in the nourishment refrigerator for the next medication pass or no more than 48 hours.

6. Residents receiving MED PASS® 2.0/MED PASS® NSA Supplements will be evaluated routinely by the consultant dietitian, certified dietary manager and licensed nursing personnel to assess progress toward nutritional goals and to determine need for continuation on the medication pass program.

7. Assignment of residents to the MED PASS® 2.0/MED PASS® NSA program will be based on the initial nutritional assessment by the consultant dietitian/certified dietary manager and routine nutrition risk monitoring conferences with dietary, nursing and other pertinent disciplines.

8. Continuation of the menu fortification program and additional between meal snacks/supplements will be evaluated based on each resident's nutritional needs and level of acceptance.

V. Sanitation Issues

  • MED PASS®* products can safely remain on a medication cart for 6 hours as long as this product is handled in a sanitary manner (e.g. avoiding touch contamination) while pouring into cups.
  • Cover, label and refrigerate opened containers of MED PASS®* products and discard after 48 hours.
  • When adding a flavor packet to MED PASS®* products, the product can still remain on the medication cart for 6 hours at room temperature, but product must be discarded at the end of this time.

VI. Drug Nutrient Interactions

  • The administration of medications with MED PASS® 2.0/MED PASS® NSA is generally safe and when administered at the recommended 60 cc dosage, minimal drug nutrient interactions should occur.
  • With some medications, the iron, calcium, magnesium and/or protein content of the liquid/food being given with the medications may decrease the absorption of the particular drug. However, the mineral and protein content is minimized when only 2 oz. of MED PASS® 2.0/MED PASS® NSA is given per dosage.
  • The mineral and protein content of each MED PASS® 2.0/MED PASS® NSA serving:


 
2 oz. MED PASS® 2.0

 
2 oz. MED PASS® NSA
5 gm PRO5 gm PRO
4.5 mg Iron< 1 mg Iron
62.5 mg Calcium110 mg Calcium
25 mg Magnesium25 mg Magnesium

Further concerns regarding drug nutrient interactions should be discussed with your pharmacist. A "Drug Nutrient Interaction Chart" is provided as a reference for you.

VII. Activities

1. Review MED PASS® Program P&P

2. Discuss handouts

3. Sample MED PASS® 2.0/MED PASS® NSA products

4. Administer a Post Test

MED PASS®* — Implementation Checklist

Completion Date
Conduct interdisciplinary care meeting with RD, CDM and Nursing to identify residents nutritionally at risk____________________
Determine number of residents appropriate for MED PASS® 2.0/MED PASS® NSA Supplement Program____________________
Notify physicians of MED PASS® 2.0/MED PASS® NSA Supplemetation Program____________________
Receive physician orders for specific amounts and frequency and update in-house physician orders____________________
Inservice nursing and dietary personnel prior to implementation____________________
Establish MED PASS® 2.0/MED PASS® NSA stocking schedule between dietary and nursing____________________
Implement Med Pass® 2.0/MED PASS® NSA Supplement Program with medications____________________
Monitor acceptance and weight status of residents routinely____________________

* Includes MED PASS® No Sugar Added (NSA)

Potential Drug Nutrient Interactions

The following medications may have a nutrient interaction with MED PASS® 2.0/MED PASS® NSA especially if given in amounts greater than 2 oz./serving. If you have questions, please review with your local pharmacist.

MedicationClassificationPotential Interaction / Dietary Significance
levodopaAntiparkinsonDo not take with high protein foods. Limit Pyradoxine to < 5 mg/day. Do not take with amino acids or protein hydrolysates. (MED PASS® = 5 gm PRO/2 oz)
levodopa and carbidopa
Sinemet
AntiparkinsonCarbidopa prevents negative Pyradoxine effect. Probably best to avoid taking with high protein foods and amino acids. (MED PASS® = 5 gm PRO/2 oz)
levothyroxine
Synthroid
Thyroid HormoneTake on an empty stomach before breakfast. Take iron supplement separately by 4 hours as med may < absorption. (MED PASS® = 4.5 mg Fe/2 oz)
methyldopa
Aldomet
Antihypertensive* Take iron supplement separately by 2 hours. (Decreases drug absorption.) (MED PASS® = 4.5 mg Fe/2 oz)
phenytoin
Dilantin
Anticonvulsant* Take calcium and magnesium supplement separately by 2 hours. Take with food to lower GI distress. Tube feedings decrease bioavailability of the drug. NOTE: May want to avoid MED PASS® with this medication due to its calcium and magnesium fortification.) (Calcium 62.5 mg and Magnesium 25 mg/2 oz)
tetracyclineAntibioticTake with 8 oz water 1 hour before or 2 hours after food or milk. Take calcium, iron, magnesium, zinc or MVI with minerals separately by 3 hours. (Forms chelates with these minerals.)
erythromycinAntibioticOptimal - Take on empty stomach 1 hour before or 2 hours after meal. May take with food to lower GI distress. * Administration of medication with MED PASS® 2.0 is unlikely to cause adverse effects.
Digoxin
Digoxin, Lanoxin
Cardiotonic, AntiarrythmicTake separately from high bran fiber or high pectin foods. Magnesium supplement lowers absorption of drug. Caution with calcium supplement. (MED PASS® contains 25 mg / 2 oz magnesium supplementation.)
quinolones
Cipro
Floxacin
AntibioticsTake 1 hour before or 2 hours after eating. (Calcium and iron can decrease drug absorption.)

Administration of medication with calcium does not decrease absorption, but iron content of food/fluid needs to be considered.
Calcium - 62.5 mg
Iron - 4.5 mg

verapamil HCl
Calan
Antihypertension
Antiarrythmic
Calcium Channel Blocker
Administration of medication with calcium containing food/beverage is unlikely to alter the effect of the medication.

Unintended Weight Loss—Identification and Prevention—Post Test

1. Anorexia and weight loss are the most prevalent nutritional disorders found in the LTC setting.

True or False

2. Common conditions associated with undernutrition (malnutrition) include:

a) anemia
b) pressure ulcers
c) cognitive abnormalities
d) all of the above

3.An initial nutritional assessment is key in identifying clinical conditions that may put the resident at risk for unintended weight loss.

True or False

4. Residents identified as "potential for weight loss" will have one or more of the following conditions:

a) dysphagia
b) depression
c) ideal body weight < 90%
d) dehydration
e) all of the above
f) b, and d

5. Providing oral supplementations to residents is one method to meet resident's nutritional needs.

True or False

6. Oral supplements, such as MED PASS® 2.0 , given at medication passes promote positive results (weight gain) due to:

a) routine distribution of product by designated personnel
b) small volumes given more frequently
c) flavor and color of product
d) a & b only
e) all of the above

7. Oral supplementations, such as MED PASS® 2.0, are usually given to residents in the amounts of

(Quantity) cc at medication passes.

8. Oral supplementation, such as MED PASS® 2.0, can be given to residents prior to assessing their nutritional needs.

True or False

9. Residents receiving oral supplements need to be monitored and evaluated routinely by the interdisciplinary health care team.

True or False

10. Supplements, such as MED PASS® 2.0, can safely remain on a medication cart up to six hours if product is handled in a sanitary manner.

True or False

Unintended Weight Loss—Identification and Prevention—Post Test Answers

1. True.The prevalence of undernutrition in long term care facilities has been reported to range from 20% - 54%.

2. d) -Numerous conditions are associated with undernutrition including anemia, pressure ulcers and cognitive abnormalities.

3. True.A thorough initial nutrition assessment is the key in identifying residents for nutritional risk.

4. f) -Dysphagia, depression and dehydration are just three of the numerous conditions that may be associated with potential for weight loss. Ideal body weight at < 90% is not considered a risk factor.

5. True.Oral supplementation is only one method to provide the additional calories and protein that a resident may need.

6. a) -Studies have shown that providing small volumes of oral supplementations frequently by designated personnel usually promises weight gain for nutritionally at risk residents.

7. 60 - 90 cc -The success of the program is serving small volumes of supplementation more frequently.

8. False.Residents must be assessed for their nutritional needs by dietetic professionals and the health care team to ensure the appropriate treatment is provided.

9. True.Routine monitoring of the resident by the health care team is essential to ensure positive outcomes are being achieved from the treatment plan.

10. True.MED PASS® 2.0 can safely remain on a medication cart up to 6 hours as long as product is covered with avoidance of touch contamination. However, residents usually enjoy a chilled product!

MED PASS® 2.0 Supplement Approval Form

Dear Doctor,

Nutrition intervention is the key in achieving a cost effective weight gain and wound-healing program. Providing additional calories and protein to a resident's diet, in concentrated form, will help promote weight gain and healing of pressure ulcers or wounds. The interdisciplinary care team at _________________ (Facility Name) has developed a new program using Hormel Health Labs MED PASS® 2.0 to support weight gain and wound healing for the nutritionally at risk residents. Offering 60-90cc of Med Pass® 2.0 during routine medication pass allows residents to receive additional calories and protein without interfering with meals.

MED PASS® 2.0 is a lactose-free, 2 cal/cc formula that contains 480 calories and 20 grams of protein per 8 oz serving (120 cal/5 gm PRO per 2 oz). Administering small amounts of MED PASS® 2.0 with medications allows for nursing to better document intake as well as improved resident compliance. All supplement intake is recorded by nursing staff just like a medication.

We will be checking resident medications to confirm that there is no contraindication with the consumption of MED PASS® 2.0.

If you wish to have your patient participate in this program, please complete the form below and return it to the facility (or DON). Upon receiving your form, we will make the appropriate revisions to the physician orders. If you need more information, please contact me. Thank you for your approval.

Sincerely,

Approval for Use of MED PASS® 2.0 Nutrition Supplement

Resident Name _____________________________Room # ________
Supplement: MED PASS® 2.0
Supplement amount____ 60cc____ 90cc____ Other
Frequency____ BID____ TID____ QID
Signature ________________________________, M.D.Date ______________

MED PASS® NSA Supplement Approval Form

Dear Doctor,

Nutrition intervention is the key in achieving a cost effective weight gain and wound-healing program. Providing additional calories and protein to a resident's diet, in concentrated form, will help promote weight gain and healing of pressure ulcers or wounds. The interdisciplinary care team at _________________ (Facility Name) has developed a new program using Hormel Health Labs MED PASS® No Sugar Added (NSA) to support weight gain and wound healing for the nutritionally at risk residents. Offering 60-90cc of Med Pass® NSA during routine medication pass allows residents to receive additional calories and protein without interfering with meals.

MED PASS® NSA is a lactose-free, 1.66 cal/cc formula that contains 400 calories, 20 grams of protein, and 23 gm CHO per 8 oz serving (100 cal/5 gm PRO per 2 oz). Administering small amounts of MED PASS® NSA with medications allows for nursing to better document intake as well as improved resident compliance. All supplement intake is recorded by nursing staff just like a medication.

We will be checking resident medications to confirm that there is no contraindication with the consumption of MED PASS® NSA.

If you wish to have your patient participate in this program, please complete the form below and return it to the facility (or DON). Upon receiving your form, we will make the appropriate revisions to the physician orders. If you need more information, please contact me. Thank you for your approval.

Sincerely,

Approval for Use of MED PASS® NSA Nutrition Supplement

Resident Name _____________________________Room # ________
Supplement: MED PASS® NSA
Supplement amount____ 60cc____ 90cc____ Other
Frequency____ BID____ TID____ QID
Signature ________________________________, M.D.Date ______________

Inservice Training—Unintended Weight Loss—Identification and Prevention

Objectives:

Participant will be able to:

  • understand the relationship of weight loss and common conditions affecting the long term care resident
  • identify the risk factors associated with unintended weight loss
  • evaluate effective nutrition intervention programs
  • implement a MED PASS® supplementation program
  • evaluate the effectiveness of a weight management program

PROGRAM OUTLINE:

I. Effects of weight loss and undernutrition

II. Identification of risk factors

III. Effective nutrition intervention program

IV. Implementation of MED PASS® products program

V. Sanitation Issues

VI. Activities

Attendance of Participants:

MED PASS® Program

POLICY:

A. Residents identified as nutritionally at risk and exhibit one or more of the following criteria shall be referred to the MED PASS®* Program. Criteria includes:

  • Poor acceptance of routine between meal supplements.
  • Evidence of significant weight loss (5%) over a 30-day period or exhibited a trend of progressive weight loss over 3-6 months (7.5% - 10%).
  • Inability to tolerate or refusal to accept "normal" volumes of fluids per serving.
  • Diagnosis or conditions requiring increased calories and protein, i.e. Stage II or greater pressure ulcers, cancer therapy, infection, COPD.
  • Low body weight (80% or less of ideal body weight or BMI below 19) and intake less than 50% of meals.

B. Residents identified as nutritionally at risk and exhibit the following criteria shall be referred to the MED PASS® No Sugar Added (NSA) Program.

  • Diagnosis or conditions requiring increased protein and calories with need for controlled carbohydrate intake, i.e. insulin dependent diabetics with Stage II or greater pressure ulcers or multi pressure ulcer sites.

PROCEDURE:

1. Residents will receive 60-90 cc (2-3 oz) of MED PASS® 2.0/MED PASS® NSA at each medication pass based on the resident's individualized medication pass routine, care plan and physician order.

2. MED PASS® 2.0 provides 120 calories, 5 gm PRO per 2 oz. MED PASS® NSA provides 96 calories, 5 gm PRO and 5.7 gm CHO per 2 oz. serving. (3 - 2 oz. servings daily would equal one CHO exchange.)

3. The MED PASS® 2.0/MED PASS® NSA order will be placed on the medication administration record (MAR) and signed out as a routine medication or treatment. The amount of MED PASS® 2.0/MED PASS® NSA taken will be documented on the MAR and signed out by the designated person passing the medications.

4. A full day's supply of MED PASS® 2.0/MED PASS® NSA will be delivered from dietary to the nourishment refrigerator located at the nursing Unit on the evening prior to the follow day's supplement pass. If MED PASS® 2.0/MED PASS® NSA remains in nourishment refrigerator at the next delivery, the stock will be rotated by designated delivery person to insure the FIFO (first in, first out) principle.

5. If partial containers of MED PASS® 2.0/MED PASS® NSA are left after a medication pass, the remaining quantity will be stored in the nourishment refrigerator for the next medication pass or no more than 48 hours.

6. Residents receiving MED PASS® 2.0/MED PASS® NSA Supplements will be evaluated routinely by the consultant dietitian, certified dietary manager and licensed nursing personnel to assess progress toward nutritional goals and to determine need for continuation on the MED PASS® program.

7. Assignment of residents to the MED PASS® 2.0/MED PASS® NSA program will be based on the initial nutritional assessment by the consultant dietitian/certified dietary manager and routine nutrition risk monitoring conferences with dietary, nursing and other pertinent disciplines.

Nutrient Comparison of MED PASS® 2.0 Supplement & Market Brand Supplements

Shelf Stable:

BrandMed Pass 2.0™Two Cal HNDeliver 2.0Nutren 2.0Resource 2.0
CompanyHormel Health LabsRossMead JohnsonClintec/NestlesNovartis
Serving Size30 cc (1 fl. oz.)30 cc (1 fl. oz.)30 cc (1 fl. oz.)30 cc (1 fl. oz.)30 cc (1 fl. oz.)
Calories6060606060
Cal/cc2.02.02.02.02.0
Total Fat, g32.733.12.4
Saturated Fat, g.44NANANANA
Protein, g2.252.52.22.42.5
Protein/cc, g.08.08.08.08.08
Carbohydrate, g5.96.45.95.87.25
Sodium3543.12523.7538.2537.5
Potassium4572.55056.662.5
Fortification3.1-5%3.1-5%3-7.4%4.1-8.4%3.1%

Frozen:

BrandGreat Shake™Plus.Resource Shake PlusMightyShake® Plus
CompanyHormel Health LabsNovartisHormel Health Labs
Serving Size1 fl. oz.1 fl. oz.1 fl. oz.
Calories57.56050
Cal/cc1.912.01.66
Total Fat, g1.7521.875
Saturated Fat, g.5NA1
Protein, g21.8751.875
Protein/cc, g.066.0625.0625
Carbohydrate, g8.258.6257.25
Sodium35.7532.532.5
Potassium6037.560
Fortification3.75%4.375%4.375%

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